HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 CRICKET LANE 10/16/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Lefti rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stabw
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: eallOnsT`'
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location_where contents were disposed:
L gHaul
Lowell Waste Water
C
SignD- S.
Date
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